amalgam associated oral lichenoid reaction – a case reportjrdindia.org/ver2/app/upload/case...
TRANSCRIPT
Kharangate N et al IJRD ISSUE 3, 2013
Downloaded from www.jrdindia.org - 134 -
Amalgam Associated Oral
Lichenoid Reaction – A Case Report
Nupur Kharangate * MDS; Nigel R. Figueiredo ** MDS; Ida de Noronha de Ataide *** MDS;
Marina Fernandes # MDS
* Former Post-Graduate Student, Department of Conservative Dentistry and Endodontics, Goa Dental College &
Hospital, Bambolim – Goa, INDIA ** Former Post-Graduate Student, Department of Oral Medicine and Radiology,
Goa Dental College & Hospital, Bambolim – Goa, INDIA *** Professor & Head, Department of Conservative
Dentistry and Endodontics, Goa Dental College & Hospital, Bambolim – Goa, INDIA # Lecturer, Department of
Conservative Dentistry and Endodontics, Goa Dental College & Hospital, Bambolim – Goa, INDIA
Address for correspondence: Dr. Nigel R. Figueiredo, Address: House No. 685, Santerxette, Aldona, Bardez – Goa, INDIA. Pin Code: 403508 Telephone No.: +91-9822129159 Email: [email protected]
Abstract : Oral lichenoid reactions are considered variants of oral lichen planus and may be regarded as a disease by itself or as an exacerbation of an existing oral lichen planus by the presence of medication or dental materials. They represent a type IV hypersensitivity reaction and most commonly affect the oral mucosa in direct contact with an amalgam restoration. Oral lichenoid reactions can cause significant discomfort for the patient and hence dentists should be aware of their occurrence, diagnosis and management. We report a case of oral lichenoid reaction of the left buccal mucosa associated with an amalgam restoration on tooth #27. Complete healing of the lesion was noted following replacement of the amalgam with an intermediate restoration, followed later by a glass-ionomer restoration.
Keywords: amalgam, lichenoid reaction, oral lichen planus
.
INTRODUCTION
The human oral mucosa is often subjected to
many noxious stimuli, either hot or cold, acidic or
alkaline substances, spicy foods, among others. In
the dental environment, substances identified as
allergenic include local anaesthetics, antibiotics,
restorative materials, and latex. (1) Silver
amalgam has been used as a dental restorative
material for over one hundred and eighty years
and still remains the most commonly placed
filling material in the world. (2) Its superior
compressive strength and minimal technique
sensitivity makes it an ideal material for posterior
restorations and core build-ups. (3)
Pinkus (1973) first coined the term “lichenoid
tissue reaction” to describe the histological pattern
featuring damage to keratinocytes, now referred
to as apoptosis, infiltrate of inflammatory cells in
the connective tissue which may extend into the
epithelium and keratosis or hyperkeratosis. (2,4)
The oral lichenoid reaction is a lesion
indistinguishable clinically and histologically of
the oral lichen planus. However, most oral
lichenoid reactions disappear when the causative
substance (drug / restorative material) is
eliminated. (1)
Oral Lichenoid Reactions (OLR) involve mucosae
in direct contact with amalgam restorations. They
generally represent a type IV hypersensitivity
reaction. Most often the allergen is mercury, but
occasionally, the response may be to one of the
other components of the amalgam alloy such as
copper, tin or zinc. (5) Mercury salts that
accumulate in healthy and damaged oral mucosa
CASE REPORT
Kharangate N et al IJRD ISSUE 3, 2013
Downloaded from www.jrdindia.org - 135 -
will cause this hypersensitivity reaction in only a
susceptible minority of the population with
resulting reticular white patches, papules, plaques,
erosions, or ulceration, similar to that found in
Oral Lichen Planus (OLP) - hence the
terminology ‘lichenoid’. (2)
This case report describes a case of oral lichenoid
reaction associated with an amalgam restoration
in the left maxillary second molar.
Case Report
A 26 year-old male patient presented with a chief
complaint of pain in relation to the upper left
posterior tooth for the past one month. Clinical
examination revealed a severely carious maxillary
left second molar 27. After a detailed clinical and
radiographic examination, root canal treatment of
27 was carried out. Silver amalgam was placed as
a post-endodontic restoration (Figure 1).
Figure 1: Amalgam restoration on 27
After seven days, the patient reported to the
department with a complaint of burning sensation
in relation to the maxillary left vestibule. Oral
examination revealed presence of a reddish-white
lesion on the left buccal mucosa, adjacent to the
amalgam restoration (Figure 2).
The lesion showed a reticular pattern with a
reddish inflamed area surrounding it. It was non-
scrapable and tested Candida negative. The
patient did not have any other dental restorations
in the mouth. The patient’s oral hygiene was
fairly good. However, small vesicles were noted
over the left angle of mouth and chin region
(Figure 3).
Figure 2: Lichenoid lesion on the left buccal mucosa
in relation to 27
Figure 3: Vesicles around left angle of mouth and
chin
A cutaneous patch test was done to detect contact
hypersensitivity. Alloy powder and mix were
tested separately on the skin on the back of the
patient.
The patient reported back after 48 hours with a
complaint of itching on the mix patch [Alloy +
Hg]. The patches were removed and examined. A
slight erythematous reaction was noted on the mix
patch area. Allergy testing with respect to dental
restorative materials revealed that the patient was
allergic to silver and tin which are the major
constituents of amalgam. A provisional diagnosis
of an amalgam associated oral lichenoid reaction
was thus made.
Kharangate N et al IJRD ISSUE 3, 2013
Downloaded from www.jrdindia.org - 136 -
A biopsy was done to histologically confirm the
nature of the lesion. Pathologic study of the lesion
showed a squamous epithelium with irregular
acanthosis and foci of parakeratosis, with marked
spongiosis and exocytosis, and presence of
lymphocytes in the stratum corneum. The
underlying stroma showed a chronic
inflammatory infiltrate affecting the basal layer. It
was decided to replace the amalgam restoration
with a non-metallic interim restoration and
follow-up the case. A final diagnosis of amalgam-
associated oral lichenoid reaction was thus made.
The patient was informed of the condition and a
decision to replace amalgam restorations with a
non-metallic interim restoration was taken.
The amalgam restoration was replaced with a
Type II Glass-ionomer restoration (Figure 4).
Figure 4: Replacement of amalgam restoration with
glass-ionomer restoration
The patient was asked to report after one week for
a follow-up. Following a week, the patient
reported with relief of symptoms. On
examination, there was a reduction in the size and
severity of the lesion. There was also complete
healing of the vesicles in the left angle of mouth
and chin region. One more review conducted after
3 months revealed complete clinical healing of the
lesion (Figures 5, 6).
Discussion
Oral lichenoid reactions are considered variants of
oral lichen planus. They may be regarded as a
disease by itself or as an exacerbation of an
existing oral lichen planus, by the presence of
medication or dental materials. Drugs such as
beta-blockers, dapsone, oral hypoglycemics, non-
steroidal anti-inflammatory drugs (NSAID’s),
penicillamine, phenothazines and sulfonylureas
have been associated with lichenoid reactions.
Besides drugs, lichenoid reactions have also been
associated with dental materials like amalgam,
composite and dental acrylics. (6)
Figure 5,6: Complete healing of lichenoid reaction
following replacement of amalgam restoration
OLRs are usually seen in middle-aged
individuals, with a slight female predominance.
(3,7) According to van der Waal (2009), OLRs
can be classified into four types as follows: (i)
amalgam restoration, topographically associated
lesions, (ii) drug-related lichenoid lesions, (iii)
lichenoid lesions in chronic graft versus host
disease, and (iv) lesions that have a lichen planus-
like aspect, but that lack one or more
characteristic clinical aspects. (8)
The typical clinical presentation of both OLP and
OLR can be reticular white patches, papules, or
plaques with or without erosions or ulcerated
areas. OLP is a more widespread condition
involving many anatomical sites within the oral
cavity (or elsewhere including skin and genitalia)
and distinct from OLR. The clinical diagnosis is
further complicated because similar oral lesions
can occur as a result of drug-related lichenoid
reactions or as graft-versus-host disease, discoid
lupus erythematosus, and systemic lupus
erythematosus. Diagnosis in such cases is
facilitated by a detailed history, clinical findings,
and immunohistological findings. (2)
OLRs caused by hypersensitivity to amalgam or
its constituents typically have a clear anatomical
relationship to the dental amalgam restoration, so
they are usually unilateral and not symmetrical.
Kharangate N et al IJRD ISSUE 3, 2013
Downloaded from www.jrdindia.org - 137 -
(2,5) They are most commonly seen on the buccal
mucosae and tongue where the covering lining
mucosa comes in contact with restorations. The
gingivae, palate, or floor of mouth, being sites
further away from restorations, are rarely affected,
and patients almost never have associated
cutaneous symptoms. These clinical features help
to distinguish OLR from OLP and other
conditions. (2) The lesions can be asymptomatic
or patients may occasionally complain of soreness
or itching especially with hot or spicy food. (7)
Certain oral complications such as metallic taste
or dry mouth can be observed. (9)
Histopathologically, the presence of a mixed
subepithelial infiltrate, in contrast to the strict
lympho-histocytic infiltrate that defines OLP, and
a deeper more diffuse distribution within the
lamina propria and superficial submucosa is
thought to serve as a marker of a lichenoid oral
lesion. (8)
The diagnosis of OLR relies on important aspects,
such as the clinical appearance of the lesions, the
lack of migration, and the association with
adjacent amalgam restorations. Although there is
no specific test for diagnosing OLRs, skin-patch
testing can be used to identify the allergen
responsible for the hypersensitivity. Patch testing
is done by using commercially available kits
which are typically placed on the skin of the back
or fore arm in wells and held in place for 48 hours
with hypoallergenic adhesive tape. The test results
are generally read at 48 and 72 hours but evidence
has shown that late readings at 10–14 days can
capture previously missed positive reactions. (2)
Management of lichenoid lesions for which a
distinct cause can be found (amalgam, drug
related, chronic graft versus host disease)
depends, indeed, on the etiology. Replacement of
amalgam restorations, anatomically related to the
lichenoid changes, will usually result in
regression within several months. (4,8) When the
amalgam restoration is removed, it should be
done using rubber dam, abundant irrigation and
high aspiration volume to diminish exposition to
the material. (1)
The malignant potential of lichenoid reactions is
controversial and generally assumed to be quite
rare. However, patients should be monitored on a
regular basis until complete resolution of the
lesion occurs.
Conclusion
Despite the advent of new synthetic non-metallic
restorative materials, silver amalgam remains the
most widely used and cost-effective material in
restorative dentistry, mainly due to its superior
strength and minimal technique sensitivity. Local
allergic reactions are rare, and when they occur,
they can be eliminated by substitution with glass
ionomer or composite resins. The scientific
evidence available does not justify the
discontinuation of the use of amalgam, nor does it
recommend the removal and replacement of
satisfactory amalgam fillings with other
restorative materials.
References
1. Segura-Egea JJ, Bullon-Fernandez P (2004)
Lichenoid Reaction Associated To Amalgam
Restoration. Med Oral Patol Oral Cir Bucal 9,
421-424.
2. McParland H, Warnakulasuriya S (2012) Oral
Lichenoid Contact Lesions to Mercury and Dental
Amalgam - A Review. J Biomed Biotechnol,
589569.
3. Ataide IN, Singh TK, Fernandes M (2011)
Management Of Amalgam-Associated Lichenoid
Reaction – A Case Report. Int J Dent Case
Reports 1, 7-14.
4. Grossman S, Garcia BG, Soares I, Monteiro L,
Mesquita R (2008) Amalgam-associated oral
lichenoid reaction: Case report and management.
Gen Dent 56, e9-e11.
5. Samuel R, Gulve MN, Golvankar K (2012) A
possible link between amalgam restorations and
lichenoid reactions: A case report. J Int Oral
Health 4, 53-56.
6. Ismail SB, Kumar KK, Zain RB (2007) Oral
Lichen Planus and Lichenoid Reactions:
Kharangate N et al IJRD ISSUE 3, 2013
Downloaded from www.jrdindia.org - 138 -
etiopathogenesis, diagnosis, management and
malignant transformation. J Oral Sci 49, 89-106.
7. Cekova M, Kisselova A, Yanev N (2010)
Lichenoid Reactions Due To Dental Restorative
Materials. Biotechnology & Biotechnological
Equipment 24, 1874-1877.
8. van der Waal I (2009) Oral lichen planus and
oral lichenoid lesions: a critical appraisal with
emphasis on the diagnostic aspects. Med Oral
Patol Oral Cir Bucal 14, e310-e314.
9. Sarode SC, Sarode GS, Kalele K (2012) Oral
Lichenoid Reaction: A Review. International
Journal of Oral & Maxillofacial Pathology 3, 17-
26.